| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
161 |
160 |
$6K |
| D1351 |
Sealant - per tooth |
254 |
61 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
162 |
161 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
29 |
$3K |
| D1206 |
Topical application of fluoride varnish |
107 |
107 |
$3K |
| D0251 |
|
55 |
54 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
52 |
50 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
57 |
$1K |
| D1353 |
|
63 |
18 |
$590.00 |
| D0603 |
|
107 |
106 |
$585.00 |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$430.00 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$235.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
47 |
$168.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$156.00 |